Citation Nr: 1642669 Decision Date: 11/07/16 Archive Date: 11/18/16 DOCKET NO. 13-09 694 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a back disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from June 1997 to June 2001, and January 2003 to January 2004. This matter comes to the Board of Veterans' Appeals (Board) from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which, in pertinent part, denied service connection for residuals of unspecified back injury. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran seeks service connection for a back disability, which he contends he incurred during his military service in a football injury. The service treatment records show that in October 1999 the Veteran was playing tackle football when a helmet collided with his right lower back. Flexion of muscle intensified pain; but there was no pain with leg extension. He was assessed as having a bruised muscle. At separation from the first period of service, clinical evaluation of the spine was normal. The Veteran also denied any back pain on a post-deployment physical in April 2003 during his second period of service. After service, however, the Veteran noted on a VA treatment record in June 2010 that he had experienced back pain since his military service. He also submitted buddy statements in July 2010 noting that they had witnessed the Veteran experiencing severe back pain since military service. The Veteran underwent a VA examination in May 2012 and was diagnosed with degenerative disc disease of the thoracolumbar spine and status post thoracolumbar compression fractures. The Veteran noted that he had been diagnosed with this condition three years prior by Discover Chiropractor, Henry Medical Center. These records are not in the file. The examiner determined that the Veteran's back disability was not related to military service, as review of the medical records did not identify any significant in-service event or injury resulting in residual compression fractures as identified on x-rays with associated disc disease. It was noted that an in-service football-related muscle strain of the back would not expect to result in these findings. Thus, the examiner determined that the Veteran's current back disposition more likely occurred independent of military service. Review of the record shows that the Veteran initiated treatment at the VA medical center in June 2010. However, it appears that he had treatment for his back prior to this, since the VA examination report in May 2012 shows that the Veteran was apparently diagnosed with residuals of compression fracture and degenerative disc disease in 2009. The Veteran submitted a VA-Form 21-4142 for treatment from Drs. Amanda and Jeremy from Discover Health, but did not include the dates of treatment. The private chiropractor records should be obtained, if feasible. A supplemental opinion also should be provided, which takes into account any additional evidence pertaining to the Veteran's claim and the Veteran's and his acquaintances' statements that he has experienced back pain since his military service. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain any recent treatment pertaining to the lumbar spine from the VAMC in Atlanta dated since January 2015. 2. Ask the Veteran to identify all private medical care providers that have treated him for his back, including chiropractic treatment from Discover Health/Chiropractors with Drs. Amanda and Jeremy, and/or at Henry Medical Center. Make arrangements to obtain all records that he adequately identifies. 3. Schedule the Veteran for a VA orthopedic examination for his lumbar spine. The VBMS file must be made available to, and reviewed by, the examiner. All appropriate testing should be conducted including x-ray and/or MRI studies. Then the examiner also should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any present lumbar spine disability had its clinical onset during active service or is related to any in-service disease, event, or football injury in October 1999. In providing this opinion, the examiner should acknowledge the following: (a) The service treatment records show that in October 1999 the Veteran was playing tackle football when a helmet collided with his right lower back. Flexion of muscle intensified pain; but there was no pain with leg extension. He was assessed as having a bruised muscle. (b) At separation from the first period of service, clinical evaluation of the spine was normal. The Veteran also denied any back pain on a post-deployment physical in April 2003 during his second period of service. (c) The Veteran noted on a VA treatment record in June 2010, however, that he had experienced back pain since his military service. He also submitted buddy statements in July 2010 noting that they had witnessed the Veteran experiencing severe back pain since military service. (d) The Veteran underwent a VA examination in May 2012 and was diagnosed with degenerative disc disease of the thoracolumbar spine and status post thoracolumbar compression fractures. The Veteran noted that he had been diagnosed with this condition three years prior by Discover Chiropractor, Henry Medical Center. The examiner should note that the Veteran is competent to state that his back has been hurting since service. A complete rationale for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 4. Ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, return the case to the examiner for completion of the inquiry. 5. Finally, readjudicate the claim on appeal. If the benefit remains denied, issue the Veteran and his representative a Supplemental Statement of the Case and allow for a reasonable period to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).